[MACROSCOPIC HEMATURIA AND LYMPHATIC SWELLING AS INDICATORS FOR SURGERY IN PAPILLARY RENAL CELL CARCINOMA MIMICKING A HEMORRHAGIC CYST: A CASE REPORT].

A 78-year-old man presented with macroscopic hematuria. Non-contrast computed tomography (CT) performed at the initial visit suggested a possible renal malignancy. Subsequent contrast-enhanced dynamic CT revealed a 3-cm non-enhancing renal mass in the left kidney with a shadow defect, raising suspicion of renal pelvic carcinoma localized to the upper calyx. Enlarged lymph nodes were also observed around the left renal vasculature. Retrograde pyelography and urine cytology showed no evidence of urothelial carcinoma. Magnetic resonance imaging (MRI) demonstrated a well- capsulated non-enhancing mass with restricted diffusion on diffusion-weighted images-findings interpreted as recent hemorrhage within a hemorrhagic cyst. Color Doppler ultrasonography revealed no internal blood flow. Follow-up CT and MRI were scheduled for three months later. However, recurrent macroscopic hematuria and persistent lymphadenopathy raised concerns for malignancy. Because renal cell carcinoma could not be excluded, robot-assisted laparoscopic radical nephrectomy was performed. En-bloc resection of the left kidney, including Gerota's fascia and regional lymph nodes surrounding the aorta and renal vessels, was conducted. Histopathological examination revealed papillary renal cell carcinoma, type 2, G2, with a tumor size of 3.2×3.2 cm (pT1a). The tumor was predominantly hemorrhagic, with minimal viable carcinoma tissue. Nevertheless, cancer cells had infiltrated the renal parenchyma (Ly1, V1) beyond the main tumor and metastasized to regional lymph nodes (pN1). This case highlights the importance of considering surgical intervention at the initial presentation when macroscopic hematuria and lymphadenopathy are present, as no reports exist of a hemorrhagic renal cyst accompanied by lymphadenopathy. No recurrence has been observed for 10 months after surgery without treatment.